How do you differentiate between vegetation and torn chordae tendineae (heart valve cords) on a Transesophageal Echocardiogram (TEE)?

Differentiating Vegetation from Torn Chordae Tendineae on TEE

While TEE has 90-100% sensitivity for detecting vegetations in infective endocarditis, it may not reliably discriminate between thickened valves, valvular nodules, and vegetations, and importantly, it cannot always differentiate between vegetations and torn chordae tendineae based on imaging characteristics alone—clinical context and specific echocardiographic features must guide the distinction. 1

Key Distinguishing Features

Attachment and Location

• Torn chordae appear as linear, mobile structures that originate from the papillary muscles and attach to the ventricular surface of valve leaflets, often creating a characteristic "snake-tongue sign" when ruptured 2, 3
• Vegetations are irregular masses that attach to the atrial surface of mitral valve leaflets or ventricular surface of aortic valve leaflets, appearing as oscillating structures on the valve itself 1

Motion Characteristics

• Torn chordae demonstrate chaotic, whip-like motion throughout the cardiac cycle, with the free end moving independently and often prolapsing into the left atrium during systole 2, 3
• Vegetations show oscillating motion that is more restricted and moves with the valve leaflet, typically remaining attached to the valve surface 1, 4

Morphologic Appearance

• Torn chordae appear as thin, linear, echo-dense structures with a distinct "snake-tongue" appearance on TEE (93% sensitivity and 95% specificity for this finding) 3
• Vegetations are typically irregular, heterogeneous masses with variable echogenicity and may show echo enhancement or abnormal echo patterns 2

Clinical Context Integration

Associated Findings

• Torn chordae are associated with:

  • Flail mitral valve leaflet
  • Myxomatous degeneration (showing extended subvalvular chordae)
  • Chronic rheumatic valvulitis (showing valve thickening and combined aortic valve damage)
  • Absence of fever, bacteremia, or systemic inflammatory signs 2

• Vegetations are associated with:

  • Positive blood cultures or clinical signs of infection
  • Fever and systemic inflammatory response
  • Perivalvular complications (abscesses, fistulae, valve perforation)
  • Risk factors for endocarditis 1

Hemodynamic Consequences

• Both conditions can cause severe mitral regurgitation, but torn chordae typically show:

  • Eccentric regurgitant jet directed away from the affected leaflet
  • Dilated left atrium and ventricle (chronic cases)
  • Preserved left ventricular function initially 2

• Vegetations may show:

  • Variable regurgitation patterns depending on valve destruction
  • Associated valve stenosis if vegetation is large
  • Potential for rapid hemodynamic deterioration 1

Diagnostic Algorithm

Step 1: Assess Clinical Presentation

• Presence of fever, bacteremia, or risk factors for endocarditis strongly suggests vegetation over torn chordae 1, 5
• Chronic progressive dyspnea without systemic signs suggests degenerative chordal rupture 2

Step 2: Identify Structure Characteristics on TEE

• Look for the "snake-tongue sign" (linear, whip-like structure) indicating torn chordae 3
• Identify irregular, oscillating masses attached to valve surface suggesting vegetation 1, 4

Step 3: Evaluate Associated Complications

• Search for perivalvular abscesses, fistulae, or valve perforation (suggests endocarditis) 1
• Assess for myxomatous changes or rheumatic valve thickening (suggests degenerative chordal rupture) 2

Step 4: Correlate with Laboratory Data

• Positive blood cultures mandate consideration of vegetation even if imaging is equivocal 1, 5
• Negative cultures with chronic presentation favor torn chordae 2

Critical Pitfalls to Avoid

TEE Limitations

• TEE may miss small vegetations (<5mm) or those that have already embolized 6
• Early perivalvular abscesses may appear only as nonspecific thickening, requiring repeat imaging in 3-5 days if clinical suspicion persists 6
• A single negative TEE does not exclude endocarditis when clinical suspicion is high 7, 6

Diagnostic Challenges

• Large vegetations (≥30mm) can occasionally be missed on transthoracic echocardiography but detected on TEE, emphasizing the need for TEE when bacteremia persists despite negative TTE 5
• Both conditions can coexist—infective endocarditis can cause secondary chordal rupture 2, 4
• Healed vegetations may be indistinguishable from chronic valvular changes 1

When Uncertainty Persists

• If TEE findings are equivocal but clinical suspicion for endocarditis remains high, repeat TEE in 3-5 days as vegetations may reach detectable size or abscesses may become evident 6
• Consider empiric antibiotic therapy while awaiting repeat imaging if clinical suspicion is high 6
• 3D echocardiography can better define complex lesions and their relationships to surrounding structures 1